Staff Application Step 1 of 2 50% Name* First Last Date of Birth* MM DD YYYY Are you / will you be 21 by the start of the camp session(s) you are applying for?*(All applicants 21+ must fill out a DHS form. You will be redirected upon submission)Yes I am/will be 21No I am not/will not be 21Gender*MaleFemaleWhich week(s) are you applying for?*Select all that apply, with your top choice first.K-3 Camp4th-6th Camp7th-9th CampWhat position(s) are you applying for?**must be a certified lifeguard. **must have medical experience & certifications. ***must be a pastor, vicar, seminary student, male teacher, or deacon/staff minister. Volunteer (14+) Junior Counselor (16+) Senior Counselor (18+) Aquatic Supervisor (17+)* Aquatic Assistant (17+) Cook (18+) Craft Director (18+) Activity Director (18+) Nurse (18+)** Shooting Instructor (18+) Bible Leader*** Director*** Which is your top option?Personal InformationEmail* Primary Phone (cell phone)*Secondary Phone (Home/School)Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School Address(if different than home address) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Church*Name, City (ie., Holton Lutheran, Holton)Synod*ELSWELST-Shirt Size*Adult SAdult MAdult LAdult XLAdult XXLAdult XXXLCamp-Related ExperienceHave you ever been employed at Camp Lor-Ray?*YesNoNumber of years as staff?Have you ever been employed at another camp?*YesNoName of camp?DutiesAny other experience working with children? Education & QualificationsLast school/college/seminary attended*Major (college)Current year or levelBackground CheckI understand that Camp Lor-Ray may conduct a background check and contact references. I authorize Camp Lor-Ray and its agents to request the release of my records from the agencies responsible for holding such information, to the fullest extent permitted by state and federal law. For the purpose of this background check, please complete the following:Drivers License NumberStatePlace of Birth*Race*ReferencesReference No. 1 must be your pastor. Please do not use an immediate or extended family member as a reference (unless it is your pastor). We request you include first and last names.Reference 1*(must be your pastor)Relation*Phone*Email Reference 2*(not related to you)Relation*Phone*Email Reference 3*(not related to you)Relation*Phone*Email Skills InterestWhat is your experience in... (answer only as able)Christian Education / Instruction Camping / Adventure Leading - or - Sports / Games / Crafts Leadership & Interpersonal Skills Music / Piano / Guitar / Song Leading * Why do you want to work at Camp Lor-Ray?* CertificationsList type and expiration date of all CURRENT certificates and licenses in each category.WaterfrontMedicalWildernessFood ServiceOtherAre you a licensed driver?*YesNoVolunteer DisclosureDo you have any current driving violations?*YesNoHave you ever been convicted of a criminal offense?*YesNoHave you ever been accused, charged, or convicted of a crime involving children?*YesNoHave you ever been accused, charged, or convicted of a crime involving illegal substances?*YesNoIn the past 30 days, have you abused alcohol, drugs, or used illegal drugs?*YesNoIs there anything in your background that could question you being entrusted with the supervision and caring for children and younger staff?*YesNoIf yes was answered to any of the above questions, please explain.I understand that answering falsely to any questions may result in my immediate termination from the Camp Lor-Ray staff, without compensation. Are there any times for which you would have to be absent from Camp?(If YES, please describe) Do you have any physical, mental, or emotional health issue that could impair your ability to work in a residential outdoor camp environment with limited modern facilities?*(If YES, please explain) List medications being taken, including dosage and frequencyReminder that all staff medications must be kept in a locked or secure place at Camp. Bring any medicine in original container and only the amount needed for the week. Medicine will need to remain with nurse Are medications & immunizations up to date?* (If NO, please explain) Pain Relief*(Under 18): Parents, do you give the nurse permission to give your child Tylenol for pain relief? (Over 18): Do you take pain relief? (All medication must be kept with Nurse, or in a locked vehicle)YesNoTetanus shot date (if known)AgreementBy signing this application I agree that all information is correct to the best of my knowledge. Any information found false may result in my application and my employment being denied or terminated. I agree to participate in any mandatory training, including arriving at Camp the day before my scheduled work session, and to adhere to all camp policies. I agree that Camp Lor-Ray or its agents are not liable for any use of information resulting from this application. At times, working at Camp can be physically and emotionally draining, I understand these risks and assert that I am healthy and can physically and emotionally perform the duties assigned to me in the position for which I am hired.Digital Signature*I certify that this information is true to the best of my knowledge, and I agree to Camp Lor-Ray's terms. Please type name. First Last Date* Note: I agree to be at camp at 1 p.m. the day BEFORE the respective camp session begins (Kids' Camp each week begins on Sunday). I am required to stay until clean-up duties are completed on the day AFTER (day OF for KinderCamp) that week is over. I understand an activity not related to family or school purposes may affect the approval of my application.*If you are not able to attend training, due to family- or school-related personal conflicts, please immediately contact our Camp Coordinator, David Kenyon. firstname.lastname@example.orgAgreeEmailThis field is for validation purposes and should be left unchanged.